Calcific Tendinitis
Orthopedic
Context
- Calcific tendinitis is a common self-limiting disease involving the deposition of calcium phosphate crystals in the rotator cuff tendons.
- Classified as acute (2 weeks or less), subacute (3-8 weeks), and chronic (8+) weeks.
- Majority of calcific tendinitis is idiopathic, but may be caused by systemic endocrine pathology such as diabetes or thyroid disease.
- Occurs in three stages: precalcific, calcific, and postcalcific.
- Calcific stage has formative, resting, and resorptive phases.
- Calcium is first deposited in the formative phase, then remains unchanged until resorption where is it absorbed by phagocytosis.
- The resorption phase involves an inflammatory process and is typically causes acute pain episodes.
- Clinical presentation:
- Patients typically present with gradual onset shoulder pain, decreased active range of motion, and increased disability of the shoulder.
- Up to 20%of patients may be asymptomatic.
- Most common in middle aged adults, women, and those with sedentary lifestyles.
- Supraspinatus tendons are the most commonly affected.
- Acute episodes generally resolve in 10-14 days.
Diagnostic Process
- Diagnosis is based on clinical presentation and confirmed with radiology.
- Clinical features:
- Acute or gradual onset shoulder pain.
- Often occurs or worsens at night, no history of trauma.
- Pain often localized to the superior or lateral aspect of the shoulder.
- Decreased active ROM, especially with overhead motion.
- Difficulty lying on affected shoulder.
- Posturing to relieve pain, typically internal rotation.
- Tenderness over supraspinatus tendon.
- Possible erythema and feeling of warmth (important to rule out septic arthritis).
- Acute or gradual onset shoulder pain.
- Recommended investigations:
- Shoulder XR
- Should consist of shoulder AP view, supraspinatus outlet view, and axillary views.
- Two main types of appearances on XR:
- Type 1: Fluffy appearance with ill-defined border; corresponds to the resorptive (acute) phase.
- Type 2: Homogenously dense calcium deposit with well-defined border; typically formative or resting phase and patients often have mild pain or are asymptomatic.
- Ultrasound
- Hyperechoic areas and posterior acoustic shadowing are often seen, especially in those in the formative or resting phases.
- Increased sensitivity for detection of calcium deposits.
- MRI
- Not routinely recommended but may be useful for detecting other pathologies present such as rotator cuff tears.
- Shoulder XR
Recommended Treatment
- Main treatment is conservative management.
- Overall success rate 30-80%
- NSAIDs for analgesia.
- Physiotherapy.
- Consider sub-acromial shoulder steroid injections for patients with acute or severe pain who do not respond to conservative management.
- Ultrasound guided barbotage
- Relieves pain through decompression by aspirating and washing out the calcium deposits; variable techniques are used.
- Typically use 3-5 mL of mixed saline and lidocaine solution using a 18 to 22 gauge needle.
- Afterwards, may inject additional 1 mL steroid and 2 mL lidocaine into bursa around deposit.
- 70% success rate.
- Procedure is operator dependent and invasive.
- Extracorporeal shockwave therapy
- Effective option but requires specialist involvement.
- 80% success rate.
- Limited availability, painful, and risk of local reactions.
- Surgery
- Reserved for patients who have had failure with conservative management for at least 6 months and significant functional impact.
- Can be done arthroscopically or via open surgery.
- Requires specialist involvement and is better suited for chronic cases.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Overall evidence for the management of calcific tendinitis is low and current recommendations are based on limited available clinical data. There are no definitive guidelines for the diagnosis and management, and much of the approach is based on expert consensus and current available clinical data.
Related Information
Reference List
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 17, 2022
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